• The Entrapped Radial Sheath: A Stepwise Approach Algorithm

    January 25, 2017

    By: Sridevi R. Pitta, MD, MBA, FSCAI and Rahul Sharma, MD

    Transradial catheterization is associated with a marked reduction in access site bleeding compared with transfemoral access. However, transradial arterial catheterization can result in unique challenges and complications. The most commonly encountered challenge is radial artery spasm which occurs with a frequency of 15-30% and ranges from mild to severe. The vasospastic potential of the radial artery is due to its highly muscular media and high density of alpha receptors. Refractory severe spasm is rare but can result in entrapment of the inserted radial sheath.1 According to Zencirci et al., the incidence of severe spasm with catheter entrapment was 0.7% during diagnostic procedures and 1.3% during therapeutic procedures.1 Predictors of moderate to severe spasm are multiple arterial punctures, large bore sheaths, long procedural duration, patient anxiety, and multiple catheter exchanges.2, 3 Radial sheath entrapment due to severe radial artery spasm is rare but potentially dangerous since forceful removal can result in endarterectomy or avulsion of the radial artery. This, in turn, may require emergent surgical treatment and result in serious morbidity, increased cost of care, and loss of radial artery patency.4, 5

    In this tip-of-the-month, we make the radial operator aware of techniques which have proven effective in the management of an entrapped radial sheath or catheter and highlight a stepwise approach to overcome this complication.


    Techniques for Removal of an Entrapped Radial Sheath/Catheter:

    A following stepwise treatment approach as summarized in the accompanying graphic algorithm is recommended.

    Step #1: Use vasodilators liberally as tolerated by blood pressure and heart rate (verapamil 2.5 to 5mg and nitroglycerin 200-600 mcg). Additional sedation should be administered in the form of an opioid/benzodiazepine combination.

    Step #2: If these initial steps prove ineffective, the next step is to use forearm warming techniques with a convective air patient warming system up to 15 minutes at 43°C (Warm Touch, Model WT- 5300A, Covidien, Mansfield MA, USA ).1 Alternatively, the antecubital surface of the forearm and the arm can be covered with warm towels or surgical gauzes soaked in warm water with a temperature of approximately 50° C.6 Another non-pharmacologic approach that has been described is flow mediated vasodilatation using a manual sphygmomanometer.7 In this technique, the blood pressure cuff is applied to the upper forearm and inflated 40 mmHg above the systolic blood pressure to occlude the brachial artery. The cuff is left inflated for up to 5 minutes and then rapidly deflated. Ischemia related alterations in the local chemical milieu during this so-called “clamp and release” technique lead to a potent smooth muscle relaxation response and facilitate radial sheath removal.
     

      

    » Download a visual representation of techniques outlined in step #2.

    Step #3: In case of failure of aforementioned techniques, further treatment options include deep sedation and/or general anesthesia, both of which have been shown to decrease neurogenic influences on spasm.1, 7

    Step #4: Invasive techniques such as regional nerve block and/or surgical endarterectomy represent options of last resort for instances of truly refractory spasm unresponsive to steps #1-3.1, 7, 8

    Training cath lab staff and operators on the recognition and management of rare but potentially serious complications, such as radial catheter/sheath entrapment, should be part of quality improvement efforts in cath labs using transradial access. Written radial pre-, intra- and post- procedural checklists and protocols, incorporating an algorithm as detailed below, should be considered in all transradial labs. Such documents can be used for patient care, staff training, and also aid in the management of complications.


    Stepwise Approach Algorithm for Treatment of Radial Sheath Entrapment:

    Pharmacologic

    • Systemic Vasodilators (nitroglycerin and/or verapamil)
    • Sedation (IV midazolam and fentanyl)

    Non-Pharmacologic

    • Warm Compresses
    • Forearm Heating
    • Flow Mediated Vasodilatation Technique ("Clamp and Release")

    Deep Conscious Sedation / General Aneasthesia

    • IV Propofol
    • Endotrachial Intubation

    Inavsive / Surgical

    • Regional Nerve Block
    • Endarterectomy


    References:

    1. Zencirci E, Değirmencioğlu A. Catheter entrapment due to severe radial artery spasm during transradial approach. Cardiol J. 2016; 23:324-32.

    2. Goldsmit A, Kiemeneij F, Gilchrist IC, Kantor P, Kedev S, Kwan T, Dharma S, Valdivieso L, Wenstemberg B, Patel T. Radial artery spasm associated with transradial cardiovascular procedures: Results from the RAS registry. Cathet Cardiovasc Interv. 2014; 83:E32-6.

    3. Ruiz-Salmerón RJ, Mora R, Vélez-Gimón M, Ortiz J, Fernández C, Vida Bl, Masotti M, Betriu A. Radial artery spasm in transradial cardiac catheterization: assessment of factors related to its occurrence and of its consequences during follow-up. Rev Esp Cardiol. 2005; 58:504-11.

    4. Dieter RS, Akef A, Wolff M. Eversion endarterectomy complicating radial artery access for left heart catheterization. Cathet Cardiovasc Interv. 2003; 58:478-80.

    5. Athauda-Arachchi P​‌, Dorman​ S. Retention and fracture of a hydrophilic radial artery sheath due to severe spasm. Interv Cardiol. 2012; 4:57-60.

    6. Barcm C, Kursakhoglu H, Kose S, Amasualt B, Isak E. Resistant radial artery spasm during coronary angiography via radial approach responded to local warm compress. Anadolu Kardiyol Derg. 2010; 10: 88-90.

    7. Pancholy SB, Karuparthi PR, Gulati R. A novel nonpharmacologic technique to remove entrapped radial sheath. Cathet Cardiovasc Interv. 2015; 85:E35-8.

    8. Steinberg DH. Managing complications of transradial catheterization. Cardiac Interventions Today. May 2015.